Review of Completeness of Inpatient Medical Record Filling at Permata Bunda Hospital

Diana Barsasella, Bernadus Rudy Sunindya, Yuliana Pratiwi

Abstract

Completeness of inpatient medical records is an important aspect of health services in hospitals. Incomplete medical records can hinder clinical decision-making, affect the quality of service, and risk causing errors in patient diagnosis and treatment. This study aims to analyze the level of completeness of inpatient medical records at Permata Bunda General Hospital, Tasikmalaya. The method used is descriptive univariate analysis with a sample of 30 inpatient medical record documents.
The results of the study showed that the highest completeness was found in the aspect of doctor authentication, such as signatures and full names, which reached 100%. However, the lowest completeness was found in recording the diagnosis of complications, which was only 6.67%. The main factors causing incomplete medical records include the lack of written Standard Operating Procedures (SOP), high workloads on medical personnel, and low awareness of doctors regarding the importance of complete documents.
Therefore, it is necessary to improve standard procedures, education for medical personnel, stricter supervision, and implementation of an electronic medical record system to improve the efficiency and accuracy of recording. With these improvements, it is hoped that the quality of health services in hospitals can continue to improve.